Completing and submitting this application is considered a request for coverage. You may apply only once per calendar year.

You can fill out this application online and click 'submit' OR download the form PDF (123K), print and mail it to:

Obesity Surgery Request
Regence BlueShield
P.O. Box 2998
Tacoma, WA  98401-2998

Please do not send any other paperwork or records at this time.

Click here to access the online application